[e-drug] New article on ARV Delivery in South Africa

[laingr@who.int]

E-drug: New article on ARV Delivery in South Africa
---------------------------------------------

Readers of E-Drug may be interested in a recent article in the Essential
Drugs Monitor on ARV treatment in a poor African environment.

The article is titled "Demystifying antiretroviral therapy in resource-poor
settings" and is by Toby Kasper, David Coetzee, Francoise Louis, Andrew
Boulle, Katherine Hilderbrand. The article asks the question "Is ARV
treatment possible in severely resource-constrained environments?" This
article shows that it can be achieved, by highlighting the experience in
Khayelitsha, a poor township near Cape Town, South Africa, where MÈdecins
Sans FrontiËres has been supporting a programme since 1999. This is one of
the first articles providing data to document successful treatment. The
article discusses the keys to success: affordable drugs; involvement of the
community; and involvement of the patients. It concludes that the time has
come to scale up from pilot projects to widespread access to ARV treatment.

The original article can be downloaded as an attached e-mail from Satelife
using their Getweb function. To do this send a message to
getweb@healthnet.org . Leave the subject line blank and in the message
section write:

Begin

get http://www.who.int/medicines/mon/32_11.pdf

End

While the numbers are relatively small (180 patients) the results are
impressive. After nine months, 88% of patients were alive and as many 
were very ill when they started therapy this shows that ARV's can be 
effectively used in an environment such as Khayelitsha in which 50% 
of residents are unemployed and 70% live in shacks. Much of the care 
was provided by nurses.

There are some interesting aspects of this report. The first relates to the
selection criteria for patients. There were clear criteria for inclusion
(CD4 count less than 200, WHO disease stage 3 or 4, residence in 
Khayelitsha and patients must have attended regularly for at least 3 
months) In addition a sytem was established of community input into 
the selection of patients for treatment. This careful process may 
have been an important part of their success.

The second issue that interests me is the use of CD4 and viral load counts.
Clearly for this study they needed to have this information available to
demonstrate that really sick patients were being effectively treated and
were improving. But what is not clear to me is whether this testing itself
actually changed outcomes. If these patients had been selected in the same
way and treated with empirical regimens would the results have been the
same?

The final point that interests me is the information about the effect of
treatment on the success of prevention programs. The authors say in their
final paragraph "The synergy between treatment and prevention has been
striking, with the availability of treatment providing a powerful incentive
to learn one's status. It was thus no surprise that a recent survey of nine
sites around South Africa found that Khayelitsha had the highest rates of
HIV testing and desire to be tested among those yet to be tested as well as
the highest level of condom use." Impressive!

Richard Laing (Medical Officer)
Policy, Access and Rational Use,
Essential Drugs and Medicines Policy,
World Health Organization
CH-1211 Geneva 27, Switzerland
Tel 41 22 791 4533
Fax 41 22791 4167
E-mail laingr@who.int

Access Essential Drugs Monitor #32 at http://www.who.int/medicines/mon/mon32.shtml

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